Unit 3- Head To Toe Assessment

Question 1

CAM

Answer 1

Confusion Assessment Method:
Assess for delirium
1. Acute onset and fluctuating course: does this behavior come and go or increase/decrease in severity
2. Inattention: does this patient have difficulty focusing attention, easily distracted, or difficulty following a conversation.
3. Disorganized Thinking: Is the patient thinking disorganized or incoherent? DOes the patient have: rambling speech? Or illogical flow of ideas?
4. Altered Level of Consciousness: What is the patients LOC? Vigilant, alert, lethargic, stupor, coma

Question 2

PRISME

Answer 2

Identify and address physiological, psychosocial and environmental factors
P= Pain, psychosocial
R=Restraint, retention
I= Infection, impaction, impaired cognition, intake
S= Sleep disturbance, sensory change, social isolation
M= Medication, metabolic, mobility
E= Enviroment